January 11, 2016 — As Medicaid programs in at least 34 states restrict coverage for Harvoni and Sovaldi, a growing number of patients with hepatitis C are being told they are not sick enough for treatment.
Indiana’s Medicaid program denied coverage for Harvoni because she does not yet have liver damage. According to her attorney: “If something is medically necessary, it’s medically necessary and must be covered by the Medicaid program.”
In November, the Center for Medicare and Medicaid Services sent a letter reminding states that they cannot restrict coverage for drugs that are prescribed for medically necessary conditions.
The problem is that Sovaldi and Harvoni are extremely expensive — up to $95,000 for a 12-week treatment with Harvoni. According to the Chicago Tribune, the same $1,000 pill sells for just $4 in India.
Critics of the restrictions say the up-front costs are justified by the long-term benefits, including a reduced cost of treating complications and eliminating the risk of transmitting hepatitis C to another person.
The World Health Organization (WHO) estimates that 3 million people in the United States have hepatitis C, out of 150 million worldwide. Hepatitis C is a highly-contagious virus that spreads in blood and bodily fluids, often on dirty needles or medical equipment. Infection causes liver inflammation and scarring that can lead to liver failure and death.